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HOME TELEHEATH COMPLIANCE: LITERATURE REVIEW
FINAL REPORT FOR
ONE IN FOUR LIVES / AUSTRALIAN INFORMATION INDUSTRY ASSOCIATION
TELEHEALTH RESEARCH AND INNOVATION LABORATORY
SCHOOL OF COMPUTING, ENGINEERING AND MATHEMATICS
UNIVERSITY OF WESTERN SYDNEY
MAY 2015
ANTHONY MAEDER AND NATHAN POULTNEY
Home Telehealth Compliance: Literature Review
ABSTRACT
systems suitable for delivery of Home
Telehealth services. A major attraction of
such solutions is that they enable new models
of care to be implemented, shifting towards
greater patient-centric and careteam-based
emphasis in healthcare.
This report describes a detailed review of
published scientific literature on the topic of
Home Telehealth compliance, encompassing
aspects of patient adoption and adherence. A
total of 72 peer review published papers were
selected as the most relevant representatives
of state-of-the-art contributions to the topic,
and compliance findings presented in these
papers are summarised here. Some common
characteristics for studies selected were
identified: they were mainly under 12 months
in duration, with widely varying sample sizes,
and typically 60-70% of participants were
over 50 years of age and male. In general,
there was good adherence/compliance at the
start of a study that steadily dropped off over
time, most rapidly in the period immediately
after the start. Some overall observations of
common themes across the range of papers
are provided in conclusion.
Numerous clinical trials have demonstrated
the health, economic, and social benefits of
Home Telehealth when used in specific
clinical settings. However, developers and
suppliers of both technology and services
often face questions as to the effectiveness of
these solutions, since their patient-centric
nature also implies that the subjects-of-care
have the option of “opting out” and
abandoning use of the solution. They may
also fail to make use of it in the intended way,
resulting in poorer outcomes than were
projected. The realisation of benefits can only
occur in Home Telehealth settings when
compliance levels are high, and so it is
important to establish what evidence exists to
inform this aspect of the overall Home
Telehealth “business model”.
This report describes a systematicallyconducted detailed review of published
scientific literature on the topic of Home
Telehealth compliance, encompassing aspects
of patient adoption and adherence. A
literature search strategy and filtering process
was undertaken to establish the most
relevant peer review published papers, which
serve as representatives of state-of-the-art
contributions to the topic. A total of 72
papers were selected for further in-depth
analysis, and were classified as High,
Moderate and Lower relevance in the level of
their contributions.
1. INTRODUCTION
Recently there has been rapid growth of the
Home Telehealth market, providing patient
monitoring and telecare services for
individuals who are living independently in
their own home accommodation. Much of
this growth has been stimulated by the
adoption of Home Telehealth solutions by
large corporate healthcare organizations (as
in the USA) or by government health agencies
(as in the UK and some European countries).
A further driver has been the development of
new technology components and integrated
1
The findings presented in these papers
concerning compliance to the use of Home
Telehealth systems are summarised here.
Some overall observations of common
themes and critique of recurring issues
revealed in the literature, across the range of
papers, are provided in conclusion. It is
hoped that this report will contribute to a
broader understanding of the nature of Home
Telehealth compliance, and inform future
work to deploy the associated systems.
year envelope to include the earliest home
monitoring publications.
The final overall search formula constructed
was as follows:
(adherence OR compliance OR retention OR
attitudes)
AND
(self-care OR self-management OR selftreatment OR self-monitoring)
AND
(home-monitoring OR home-system OR telehealth OR tele-medicine OR tele-care)
2. METHODOLOGY
The chosen terms included in this formula
were those deemed to be most strongly
indicative and most consistently used in
connection with the concepts being sought.
PubMed, Google Scholar and Scopus were
selected as the most appropriate sources for
searching the published literature, these
having distinctive target collections which
differ considerably from each other. PubMed
is a specialised health publications collection,
with a strict quality assurance process for
inclusion. Google Scholar is a general
automatically compiled listing with strong
search capabilities. Scopus is an academically
oriented collection with wide coverage of
both health and non-health disciplines. It is
acknowledged that compliance experiences
may also be reported in grey literature, but
that was beyond the scope of this review.
Selection of papers was undertaken using the
final overall search formula and results were
as follows:
-
The results were ordered on the basis of best
fit as determined by each source’s search
function, generally requiring at least 1 term
from each of the 3 groups of terms to be
present. Figure 1 shows the overall process.
Those papers with non-trivial citation counts
(e.g. >10 cites for papers published up to
2010, and >1 cites for papers published since
2010) occurring in the first 10 pages (i.e. the
highest rated best fits for the search results)
of all three searches were extracted. Papers
which duplicated project reporting were
omitted. This process yielded a candidate list
of 190 unique potential papers. These were
scrutinised using their titles alone to indicate
whether they were likely to be in scope for
the review. This screening stage reduced the
number retained to 121 probable papers.
Search terms were selected to cover the topic
area broadly, in three concept groups:
-
PubMed 1111 papers;
Google Scholar 6480 papers;
Scopus 9089 papers.
Adherence to Usage;
Self Care/Management;
Telehealth Systems.
A succession of trial search formulas were
developed and applied, and refinement of the
terms included in these was undertaken on
the basis of iterative inspection of their
results. Searches were limited to papers
published from 1990 onwards, providing a 25
2
Of the 121 probable papers, 72 most relevant
papers were identified on the basis of the
combination of additional information in the
keywords and abstract indicating good
alignment with the target area of the review,
and the remainder were rejected from further
consideration. The 72 most relevant papers
were then classified into High relevance (40
papers), Moderate relevance (18 papers) and
Lower relevance (14 papers) categories, on
the basis of reading their full text to establish
their direct and comprehensive contributions.
Table 1. Clinical areas covered by papers
Clinical Area
 Blood Pressure Monitoring
 Heart Failure/Stroke
Monitoring
 Diabetes
 Asthma
 Chronic Obstructive
Pulmonary Disease (COPD)
 Activity Monitoring of Daily
Living (AMDL)
 Lung Function /Respiratory
Disease
 Well-being
 Cystic Fibrosis
The 72 most relevant papers are listed in a
table in the Appendix to this report, and full
citations are provided in the References
section. The year of publication of each paper
is indicated. It may be noted that only 3 of
these papers were published prior to 2000,
and a further 12 prior to 2005, so there is a
strong bias towards recent work published in
the last 10 years. Papers concerning work
undertaken in Australia have been identified.
Prominence
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There was also a diverse range of study
methodologies applied by the authors among
the papers identified for inclusion, which are
listed in Table 2. These are tabulated here
(having been extracted from the Appendix
table) to indicate the nature of the different
scientific approaches taken, rather than to
identify any methodologies as superior.
3. COMMENTARY
The literature review conducted here
considered High relevance papers reporting
project findings, identifying factors which
favour achievement of compliance and
adherence, as well as reasons for noncompliance and non-adherence, in the area of
home-monitoring and self-management
health related devices.
Table 2. Study methodologies used in papers
Type of Study Methodology
 Randomised Controlled Trial (RCT)
 Systematic Review
 Feasibility Study
 Pilot Study
 Prospective Study
 Outcome Pilot
 Cross-sectional Survey
 Case Study
 Randomised Survey
 Literature Review
 Field Trial
 Qualitative Study/Evaluation
 Mixed Methods Study
 Longitudinal Study
Studies and interventions in several different
clinical areas were found, with information
regarding patient adherence and compliance.
These clinical areas are listed in Table 1 and
assigned to three levels of prominence, based
on number of papers and value of their
content to informing this report.
3
The following sections consider each of the
above clinical areas in turn and provide a brief
discussion of the nature of the work reported
and its contributions to knowledge on
compliance performance matters.
the GP practice monthly to have their blood
pressure checked. The resulting satisfaction
with the system after the 13 week
programme was 4.81/5.00. It was also found
that the system improved patient education
about hypertension and they felt a greater
degree of support and flexibility that "suited
the patient rather than the practice".17
3.1 Blood Pressure Monitoring
A study involving frequent home blood
pressure monitoring of 17 articles revealed
trends of compliance dropping during
weekends compared to workdays. There was
a greater degree of patient "enthusiasm" (ie;
participation) in the first two months (89%)
which then was followed by a phase lowering
to 64%. At the conclusion of the study it was
found that approximately half of the
participants would willingly continue to
monitor their blood pressure beyond the one
year study.7
In a study on blood pressure monitoring
among middle-aged Korean Americans a total
of 377 patients participated in the study.
Instructions were to take blood pressure
readings 3 times upon waking and 3 times
again before bed, at least 2 or more times a
week over a 48 week period. Through the use
of multivariate logistic regression it was found
that older participants were more compliant
than younger participants, also patients with
depressive symptoms were also less
compliant. It was found that participants that
were compliant with the instructions were 4
times more likely to control their blood
pressure by the end of the intervention in
comparison to those who were noncompliant. The results suggest that
participants who checked their blood
pressure regularly had a much greater
tendency to control their blood pressure.19
In a community-based senior centre pilot
study of blood pressure monitoring, the use
of a kiosk for taking readings steadily
increased over the trial period and was as
high as 80% in a study size of 112 participants.
The usage then begun to decline to only 47%
by 10 months. The vast majority of
intervention patients reported being "very
comfortable" with the technology by the end
of the study and reported that it was "very
easy" to use. 89% of study participants
reported they would recommend it to a
friend.16
A telephone survey was conducted with a
random quota sample of a group of nonparticipants in a home blood pressure
monitoring study. The questions were
designed to assess the use of monitors,
patients' perceived benefit, patient
communication with providers and any
barriers. 320 surveys were completed which
was a response rate of 53%. Barriers to
participation were primarily personal such as
forgetfulness, not having time to take
readings as well as self-described laziness. The
A study involving blood pressure readings
texted to a server by 124 participants was
found to be well accepted by patients
reporting high satisfaction due to the system
being easy to use and receiving valuable
feedback from their GP in regards to their
readings. This was much preferred by the
patients compared to having to physically visit
4
reasons for not communicating readings to
providers were primarily clinical factors such
as no doctor visit, the doctor didn't ask or the
patient thinking the doctor wouldn't care. At
the conclusion of the survey, the central
reporting system for the blood pressure
monitoring was over three times more likely
to be used by the patients.20
monitoring as well as the delivery of
motivational and educational materials via
text messages to the intervention group
participants. It was found that the
intervention group had a significantly higher
uptake (80%) in comparison to the traditional,
centre-based programme (62%). Adherence in
the intervention group was also significantly
higher with 94% compared to 68%, the same
was also true with the completion rate within
the intervention group; 80% compared to
47%. 38
3.2 Heart Failure/Stroke Monitoring
This study assesses the attitudes of heart
failure patients towards mobile based
telehealth monitoring using 20 heart failure
patients and 16 clinicians. It was proven that
patients preferred using the mobile
technology even more than they would using
computers. Patients and clinicians agreed that
they would happily use the system as long as
it was easy to use with clear tangible benefits,
it maintained good patient-provider
communication and did not increase the
workload. 28
3.3 Diabetes
A comparative study on the differences in
patients complying with web applications
compared to mobile applications was
conducting on telehealth monitoring
diabetes. Patients were given choice of which
modality they preferred for the telehealth
monitoring and of the 403 there were 291
that chose the app and 112 that chose the
web. Demographics of the patients were
similar but it was noted that 95% of women
preferred the app and only 68% of men
preferred the app. It was concluded that
different types of data acquisition
technologies have an important impact on the
effects of a patient’s willingness to use
telehealth monitoring. This conclusion was
drawn from the Kaplan-Meier analysis which
showed a steady decline in compliance using
mobile apps over a long period of time and a
rapid decline in using the web based
application. 15
382 patients were involved in a study relating
to home monitoring their knowledge, selfcare and adherence to a heart failure system.
Patients were assigned randomly to either
home monitoring or a usual care group and
received 4 questionnaires via post for
assessment purposes. There were baseline
differences between the groups for self-care
and self-efficacy. However, there was a
significant difference in patient knowledge
favouring the home monitoring group. After 6
months it was found that self-efficacy and
adherence improved in the intervention
group using home monitoring. 35
Another study evaluated the impacts of using
mobile phones for telehealth monitoring of
type 2 diabetes patients. This study involved
30 patients which were randomised into
intervention and control groups. Results
In a randomised controlled trial with 120
participants using a smartphone-based home
care model for cardiac rehabilitation. The
smartphone was used for health and exercise
5
favoured the intervention group showing that
HbA1c levels improved as did self-efficacy
scores. There was no improvement in the
control group. One limitation to this study is
while it is more feasible for patients to use
the technological intervention was not userfriendly. 24
During this run-in period the average
compliance was 83% with compliance varying
between 6-106%. Following this period was a
4 week follow-up. During this timeframe on
days without exacerbation compliance of
inhaled medication increased by 12% and
ranged between 21-200% per individual. On
days when patients should have doubled the
intake of inhaled medications compliance
decreased by 28% and ranged between 4694%. Additionally out of 10 who should have
doubled their inhaled medication only 3 did
so. This shows that most people are willing to
increase but not double their intake of
inhaled medication. Thus, an emphasis on the
safety of inhaled medications is needed to
reassure patients.37
A study on the use of an internet based
telehealth monitoring system for diabetes
aimed to investigate if the program improved
glycaemic control more effectively than usual
care. 248 patients between 35 and 75 years of
age were eligible for the internet based
program and were treated with insulin. It was
found that this innovative means of
telehealth monitoring could result in a better
performance of self-titration of insulin leading
to the improvement of glycaemic control. The
ideology is that the patient will discover their
own ability to monitor their diabetes resulting
in user empowerment. 25
3.5 Chronic Obstructive Pulmonary Disease
A systematic review on home monitoring of
Chronic Obstructive Pulmonary Disease
Patients (COPD) was conducted to explore the
patients’ adherence and satisfaction with the
use of telemonitoring systems. In total, 17
articles were reviewed of which 12 were
published from 2010 to the present. All
studies reviewed had similar training and data
collection processes but differed in terms of
technology used, the duration of
telemonitoring and the provision of prompts
or feedback.
3.4 Asthma
Participants involved in a mobile phone-based
monitoring system for asthma found that the
system can facilitate guided self-help
management. However, it caused a significant
dependence on professional/technology
support. In the early phases of this trial
patients were beginning to understand and
control their asthma, however; this evolved
into an unhelpful phase of being too
dependent on self-managing asthma which
raised concerns among health professionals.23
Overall, it was patients were satisfied and
found the systems to assist with monitoring
their diseases. A constraint however existed
with the usability of the systems as it was
found that they are lacking in this area and
future research should take this into
consideration.2
In a study of compliance with inhaled
medication and self-treatment guidelines for
asthma participants were given a 2 week runin period where compliance with inhaled
medication was electronically registered.
6
3.6 Activity Monitoring of Daily Living
study there was a non-adherence level of
59.4% based on patient behaviour
investigated through electronic monitoring. In
the study there were three main reasons
reported for the rate of non-adherence which
were forgetfulness (22%), lack of time (19%)
and good self-perception of health status
(19%). 40
Participants in a study involving wireless
Triaxial Accelerometer (TA) had a high
compliance rate for using the units. The TA
unit was worn on 88% of the days throughout
the study for an average of 11.2 hours per
day. It was found that the system was easy to
use and the TA unit was unobtrusive and
comfortable to wear which gives reason for
the high compliance rate.4
3.8 Well-being
In a study on home monitoring systems
compliance and technical feasibility of long
term health monitoring was conducted on 17
working age participants and 19 elderly
participants. Of this, the working age
participants collected data for a total of 1406
days with an average participation period of
83 days. In comparison, the elderly
participants collected data for a total of 1593
days with an average participation of 84 days.
Overall, users gave positive feedback and the
study showed that the data-collection rate is
between 70 and 90% for monitoring health
data. However, an unexpected issues which
were raised in this study was thunder storm
damage to equipment in homes and
scheduling differences between staff and the
participants.12
3.7 Lung Function/Respiratory Disease
Twelve participants were involved in a
feasibility study of an internet-based system
for home-monitoring lung transplant
recipients. The lung transplant recipients
demonstrated that they were able to use the
Adherence Enhancement Internet Program
(AEIP) with little training, found it acceptable
and were generally using it as a tool to
maintain or promote adherence.8
In a study measuring the acceptance of an
internet-based telemonitoring system
providing direct transmission of home
spirometry to the hospital overall patient
compliance was 55% for 2 measurements a
day and 84% for one measurement a day. This
study was based on 22 bilateral-lung and
heart-lung transplant recipients. It was
concluded that the home monitoring of
pulmonary function in lung transplant
recipients via the internet is feasible and
provides reproducible data. However, it only
has a mild sensitivity for the detection of
acute allograft dysfunction.10
3.9 Cystic Fibrosis
Five adolescents were asked to use a home
telecare system during a routine hospital visit
over one week to monitor Cystic Fibrosis.
Patients found that the system easily
recorded lung function measurements with
no supervision and indicated that it was easy
to learn and use. Patients also indicated that
feedback provided by the system and ongoing
clinical support would determine long-term
use and compliance with the monitoring
protocol.18
A study measuring adherence to regular selfmonitoring of lung function in 269 lung
transplant recipients found that across 22052
measurements performed throughout the
7
3.10 Medical Benefits from Compliance
reasons, refusal to wear the device in cold
weather, the device was believed to be "too
difficult to carry around at work" and the
frequency of the telemonitoring requirements
was deemed to be too demanding such as 3
times a day on week days.
While it was not the focus of this review, it
was noted that varying evidence of medical
benefits was reported in the papers. Only
those papers providing well founded
information with thorough quantitative
analysis of medical benefits are described
here. It is likely that a separate literature
review on that topic would reveal many more
papers, as different search terms would be
chosen to suit that context.
Five of the studies that provided information
on patient dropouts within the intervention
period had a dropout rate of 20% or more as
well as low compliance rates of 80% or less.
However, in one study it was found that the
rate of compliance was high when the patient
only had to transmit data once a day, with
compliance rates of 98% for oxygen
saturation and 83% for respiratory rate. The
compliance rate dropped significantly when
the patient was recommended to transmit
data 3 times per day instead with compliance
rates of 79% for oxygen saturation and 60%
for respiratory rate.
In a study involving intelligent home
monitoring a total of 61 alerts were recorded
with an average frequency of one alert per
month per client. 15 of the 61 alerts were
considered genuine but there were no real
emergencies recorded for the duration of the
study. Many clients in the field trial reported
enhanced fields of safety and security which
in the long run will assist with alleviating the
pressures of living independently. In turn, the
monitoring system ultimately increased the
range of care choices available to the elderly
and improved the role of the carer.22
The reasons for the dropouts were due to
usability problems in 2 studies, technical
problems in 3 studies and reasons unrelated
to the intervention itself but rather the
patient's condition in 3 studies. Relocation
was a reason for dropouts in 2 studies and
patients' death in 4 studies.2
As mentioned previously, a study on diabetes
shows that HbA1c levels and self-efficacy of
using home monitoring improved, adding an
overall health benefit to the patients in the
trial. 24
In another systematic review looking at the
evidence base for home telemonitoring for
chronic diseases it was found that regardless
of the patient's nationality, socioeconomic
status, or age, generally patients comply with
the use of a telemonitoring device/system
and programme. It was also found that there
is a greater degree of consistency with the
clinical effectiveness outcomes in regards to
telemonitoring usage in pulmonary or cardiac
studies in comparison to diabetes and
hypertension. The economics side of
telemonitoring usage was mentioned in very
3.11 Systematic Review Findings
A systematic review of home telemonitoring
in COPD 2 found that all studies had provided
information regarding patient dropouts. 3 of
the studies provided patient dropout
information prior to the intervention and
reasons for withdrawal were included in one
of the studies, this included: worsening of
patient's physical condition, financial-related
8
few studies and in the majority of studies
there was no analysis of cost-minimisation.5
4. DISCUSSION
3.12 Multi-site Multi-state Clinical Trials
A brief overview of the collective findings
reveals the following characteristics:
Unfortunately there are comparatively few
large projects that specifically examine
adherence and compliance across a variety of
patient circumstances and delivery settings.
The well-publicised Whole Systems
Demonstrator project run in the UK was
intended to synthesize a large body of
evidence from several separate studies and
was described by its investigators as a
“multisite cluster randomised trial”. 27 Its
considerations and findings in terms of
compliance appear to have varied widely
across the components of the trial, providing
some strong anecdotal insights but not a
strong systematic contribution in terms of
evidence.
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The studies selected are mainly
between 1 to 12 months in duration.
The majority (typically 60-70%) of
participants in the selected literature
are over the age of 50 and male.
Sample sizes across the selected
literature vary greatly.
In general, there is good
adherence/compliance at the start of
a study that steadily drops off over
time, most rapidly in the period
immediately after the start.
Some broad observations can be made
concerning recurring themes with respect to
adherence/compliance, in the reviewed
studies.
The recent CSIRO trial of a home monitoring
device for chronic disease at several locations
along the east coast of Australia with NBN
capability assessed various aspects related to
effective use and implementation of a home
monitoring service. The aspects of interest
are those of the participants’ satisfaction,
useability, acceptance, workload, anxiety and
strain, all of which are factors associated with
compliance or non-compliance. Entry and exit
questionnaires were utilised to gather the
aforementioned information as well as
periodic questionnaires and patient vital
signs. Data was expected to be obtained from
125 test patients and up to 250 control
patients. Clinical benefits were the focus of
the report’s findings however they indirectly
imply a “high level of acceptance by patients
and their carers”. 39
4.1 Participant Education
The greatest level of compliance has been
found within the studies involving an
education programme for the participants.
Across the publications involving an education
programme, participants display high levels of
compliance throughout most of the duration
of a study. It has been noted that when a
participant better understands their condition
and their role in managing their condition
effectively they are far more likely to comply
with the instructions provided to them in
regards to the home monitoring intervention.
The converse is also true: studies without
adequate participant education, or no
education at all beyond the basic usage of a
home monitoring system or device, tend to
9
result in lower compliance for the duration of
a study. These effects all apply after the
initial startup period of the study, when
compliance is almost always at its highest.
Non-compliance can also be an issue once
technical issues are encountered with a home
monitoring device or system. Some study
participants are hesitant to report technical
failures, feeling as if they have misused the
technology rather than realising that the
technology itself was at fault. These issues
can lead to drops in compliance in random
periods of a study and leave gaps in the data
collection.
4.2 Age Group Effects
Whilst many of the selected papers reported
on studies involving elderly participants, of
the studies involving a wider age range it was
found that elderly participants were generally
more compliant throughout a study,
compared to middle-aged or young adults.
This is most likely due to the fact that elderly
participants better understand their condition
and value the importance of managing it,
compared to younger participants who may
not prioritise the nature of their condition as
highly as the more elderly participants.
4.4 Support and Independence
Participants in some studies have reported
they feel home monitoring devices or systems
help support them in a way that allows them
to have greater flexibility in their life and be
more independent when managing their
condition. This is one of the strengths of
home monitoring compliance: once a
participant feels it empowers them, they are
far more likely to continue to comply.
However, in some cases the opposite is true,
participants may feel home monitoring
hinders their day to day lives and is more of a
burden and a tool that is tedious to deal with.
Rather than feel supported or independent,
they feel rather dependent and that the
device is intrusive on their life. Consequently
this leads to non-compliance behaviours.
4.3 Participant Misunderstanding
The literature has reported the importance of
conveying information correctly and
appropriately to potential participants for a
study regarding a home monitoring device or
system. In a few studies, a handful of
potential participants had no interest in
taking part in the study, due to the
participation instructions and lack of detailed
description of what it involves giving them a
feeling of it being too “difficult”. In particular,
with eligible elderly participants it has been
reported that they can confuse a simple home
monitoring device which has only a few
buttons to operate, with a computer. As they
are often hesitant towards computers and
lack computer competency, this tends to limit
their intake into a study. This results in nonparticipation with otherwise eligible patients,
which also further results in smaller sample
sizes within studies.
4.5 Motivation
Across studies there are clear differences in
compliance trends between motivated and
demotivated participants. Motivated
participants tend to comply consistently for
either part of or for the majority of a study,
and when given surveys or questionnaires will
report high satisfaction with the home
monitoring device or system. Demotivated
participants will frequently not comply and at
the conclusion of a study when given a survey
10
participants, and to relieve fatigue elements
experienced by clinicians due to changes in
practice associated with Home Telehealth
programmes, in conjunction with developing
business models for cost containment or
neutrality in the delivery pathways, are
therefore high priority areas for further
consideration.
or questionnaire will report forgetfulness or
laziness, as well as disinterest in the home
monitoring device or system. This direct
indication of the association between
motivation and compliance appears to be a
major but largely unaddressed factor.
5. CONCLUSION
From analysis of the High relevance papers
selected in this review, it is apparent that
there are several areas of differing clinical
focus which have attempted comparable
patient monitoring tasks within the Home
Telehealth domain, and met with generally
comparable success rates in terms of
compliance. Self-care using telehealth
monitoring systems was the major focus of
this review, rather than detailed analysis of its
use in specific clinical areas. It is not possible
to single out a particular clinical area or areas
which offer breakthrough approaches for
assuring or improving on compliance. It is
possible that a clinical area with a more highly
tuned model of care depending more closely
on the nature of the Home Telehealth
intervention, could achieve better compliance
than reported levels.
Compliance is an aspect of Home Telehealth
which has been considered in numerous
studies reported in the scientific literature,
generally in conjunction with other aspects
rather than in isolation. It is apparent from
the literature that reliable evidence of
compliance rates and factors (including
aspects such as retention, adherence,
satisfaction) is relatively thin by comparison
with analyses of clinical and economic
aspects. Existing evidence on compliance has
been obtained by different methods, and so is
not easily aggregated. It is also apparent that
compliance effects have been less rigorously
evaluated than is desirable, pointing the way
to a need for future work and the desirability
of planning for managing compliance in future
Home Telehealth projects.
The characteristic compliance profile appears
to be rapid attrition of some substantial
fraction of participants early in a project
lifecycle, followed by a more sustained level
of participation and much slower further
attrition. Factors affecting these two
components have not been well explored
scientifically, but there is wide agreement
that intuitively they include motivational and
educational aspects (affecting both patients
and careteam members) and the ability to
continue providing appropriate support to
programmes to enable sustainable long term
delivery. Ways to enthuse and inform
11
Potential papers identified from the
following sources:
PubMed (n = 1111)
Google Scholar (n = 6480)
Scopus (n = 9089)
Remaining papers
excluded based on
search engine based
poorer fit to search
Papers retained based on
search engine based best fit to
search (n = 190)
(n = 190)
Remaining papers
excluded based on title
as probable out of
scope
Papers retained based on title
as probable in scope (n = 121)
Remaining papers
excluded based on
keywords and abstract as
out of scope
Papers retained based on
keywords and abstract as in
scope (n = 72)
High Relevance Papers
(n = 40)
Moderate Relevance Papers
(n = 18)
Lower Relevance Papers
(n = 14)
Figure 1: Summary of literature search methodology for selection and categorization of papers.
12
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17
Appendix
#
1
Relev
ance
High
Year
2009
2
High
3
Paper
Type of Modality
Area of Health
Feasibility of blood pressure
telemonitoring in patients
with poor blood pressure
control
Blood Pressure
telemonitoring
device
Blood Pressure
2014
Home telemonitoring in
COPD: A systematic review of
methodologies and patients'
adherence
Home telemonitoring
systems
Chronic Obstructive
Pulmonary Disease
(COPD)
High
2008
Elderly comfort
and compliance to
modern telemedicine system
at home
Wireless
telemedicine system
at home
4
High
2004
A pilot study of long-term
monitoring of human
movements in the home using
accelerometry
5
High
2007
6
High
7
High
Sample Size
Duration
P Value
591 participants
First 6 months
Yes
Systematic Review
17 articles
included
June to
August 2012
Heart Failure
Feasibility Study
1 week
Wireless triaxial
accelerometer (TA)
Activity Monitoring
of Daily Living
Feasibility Study
24 non risky
elderly heart
patients (aged
60 +/- 5 years)
(12 male, 12
female)
6 participants
aged 80-86
years old
Systematic review of home
telemonitoring for chronic
diseases: the evidence base
Home telemonitoring
Chronic Diseases
Systematic Review
65 articles
included
1990 to 2006
2003
Pilot study of a Webbased compliance monitoring
device for patients with
congestive heart failure
Self-care compliance
device and webbased monitoring
system
Heart Failure
Pilot Study,
Randomised
Controlled Trial
3 months
Yes
2005
Daily usage and efficiency of
Home self-monitored
Blood Pressure
Feasibility Study
18 participants
(17 male, 1
female) (aged
50 to 87 years
old)
50 participants
12 months
Yes
18
Type of
Evaluation/Analysis
Randomised
Controlled Trial
2 to 3 months
Aus
Yes
remote home monitoring in
hypertensive patients over a
one-year period
blood pressure
(26 male, 17
female) (mean
age 54) (7
exclusions)
12 participants
8
High
2006
The design of an Internetbased system to
maintain home
monitoring adherence by lung
transplant recipients
Home monitoring
internet-based
system
Lung Function
Feasibility Study
9
High
2006
Mobile phone-based
surveillance of cardiac
patients at home
Home monitoring
system
Heart Failure
Feasibility Study
20 participants
(mean age 50
years)
10
High
2002
Internet-based home
monitoring of pulmonary
function after lung
transplantation
Internet-based
telemonitoring
system
Pulmonary
Function
Prospective Study
22 participants
11
High
2006
Impact of home-based
monitoring on the care of
patients with congestive heart
failure
Home-based
telemonitoring
Heart Failure
Feasibility Study
83 participants
2 months
Yes
12
High
2009
Compliance and technical
feasibility of long-term health
monitoring with wearable and
ambient technologies
Home monitoring
system
Well-being
Feasibility Study
17 working-age
participants and
19 elderly
participants
13
High
2006
Impact of monitoring
technology in assisted living:
outcome pilot
Monitoring
technology in
assisted living
Activity Monitoring
of Daily Living
Outcome Pilot
22 participants
(7 male, 15
female) (mean
age 83.79)
Working-age
participants
total of 1406
days and
elderly
participants
total of 1593
days
3 months
Yes
19
12 months
Monitored for
90 days each
(1735 days
total)
June 1998 to
September
2000
Yes
14
High
2012
Factors relating to
home telehealth acceptance
and usage compliance
In-home telehealth
(medical alarm
pendant)
Vital Signs
Randomised
Controlled Trial
15
High
2012
Web versus App–
compliance of patients in
a telehealth diabetes
management programme
using two different
technologies
Mobile app and web
interface
Diabetes
Feasibility Study
16
High
2012
TEAhM—Technologies for
Enhancing Access to Health
Management: A Pilot Study of
Community-Based Telehealth
Telehealth kiosks
Blood Pressure
Pilot Study,
Randomised
Controlled Trial
17
High
2012
A cross-sectional survey and
service evaluation of
simple telehealth in primary
care: what do patients think?
Home blood pressure
readings texted to a
server
Blood Pressure
Cross-sectional
survey
18
High
2005
Designing home telecare: a
case study in monitoring
cystic fibrosis
Home telecare
system
Cystic Fibrosis
Case Study
5 participants
(adolescents)
1 week
19
High
2010
Compliance With Home Blood
Pressure Monitoring Among
Middle‐Aged Korean
Americans With Hypertension
Home blood pressure
monitoring
Blood Pressure
Prospective Trial
48 weeks
Yes
20
High
2011
What keeps patients from
adhering to a home blood
Home blood pressure
monitoring
Blood Pressure
Random Quota
Sample
377 participants
(age range 40 to
64 years old)
(49.3%/50.7%
male/female)
316 participants
(mean age 61.4)
N/A
Yes
20
61 participants
and 29 carers
(age range of
63-95 years old)
(mean age of 80
years)
403 participants
(341 male, 62
female) (291
mainly used the
mobile app, 112
mainly used the
web interface)
112 participants
(73 controls, 43
intervention)
(mean 74.1
years old) (25%
male, 75%
female)
124 participants
12 or 24
weeks
Yes
Yes
Up to 767
days usage
Yes
Yes
10 months
13 weeks
Yes
pressure program?
21
High
2008
Attitudes of primary care
physicians and their patients
about home blood pressure
monitoring in Ontario
22
High
2000
An evaluation of an
intelligent home
monitoring system
23
High
2007
24
High
25
26
(35.1% male,
64.9% female)
149 participants
Home blood pressure
monitoring
Blood Pressure
Randomised Survey
Intelligent home
monitoring system
Activity Monitoring
of Daily Living
Field Trial
22 participants
(age range from
60s to over 85)
3 months
Understanding the potential
role of mobile phone‐based
monitoring on asthma
self‐management: qualitative
study
Mobile phone-based
monitoring
Asthma
Qualitative Study
4 weeks
2008
Evaluating the impact of
mobile telephone technology
on type 2 diabetic
patients'self‐management:
the NICHE pilot study
Mobile phone-based
self management
Diabetes
Randomised
Controlled Trial
High
2009
Web-based guided insulin
self-titration in patients with
type 2 diabetes: the Di@ log
study. Design of a cluster
randomised controlled trial
[TC1316]
Web-based diabetes
management
Diabetes
Randomised
Controlled Trial
48 participants
(34 adults and
teenagers with
asthma, 14
asthma nurses
and doctors)
30 participants
(majority
female with
mean age 55.3
years in
intervention
group and 56.7
years in control
group)
248 participants
(aged between
35-75 years)
High
2008
Current status and future
perspectives in telecare for
elderly people suffering from
Home telecare
Chronic Disease
Literature Review
21
54 articles
selected for
further
N/A
3 months
12 months
Published
between 1990
and 2007
Yes
chronic diseases
A comprehensive evaluation
of the impact of
telemonitoring in patients
with long-term conditions and
social care needs: protocol for
the whole systems
demonstrator cluster
randomised trial
Attitudes of heart failure
patients and health care
providers towards mobile
phone-based remote
monitoring
27
High
2011
28
High
2010
29
High
2009
Pilot study of a virtual
diabetes clinic: satisfaction
and usability
30
High
2011
31
High
2011
32
High
2015
33
High
2014
A pilot project for improving
paediatric diabetes outcomes
using a website: the Pediatric
Diabetes Education Portal
Telemedical homemonitoring of diabetic foot
disease using photographic
foot imaging–a feasibility
study
Telecare for Diabetes, CHF or
COPD: Effect on Quality of
Life, Hospital Use and Costs. A
Randomised Controlled Trial
and Qualitative Evaluation.
Exploring the relationship
Home monitoring
system
Heart Failure,
Diabetes and COPD
Randomised
Controlled Trial
Mobile phone-based
remote monitoring
Heart Failure
Mixed Methods
Study
Virtual diabetes clinic
Diabetes
Feasibility Study
Paediatric Diabetes
Education Portal
Diabetes
Pilot Trial, Feasibility
Study
Photographic foot
imaging device
(telemonitoring tool)
Diabetes
Electronic device
data uploading
Telemedicine service
examination
6,000
participants
(approximately)
12 months
Yes
Questionnaire
administered to
100 patients.
Semi-structured
interviews with
20 patients and
16 clinicians
17 participants
(6 males, 11
females) (age
range 22-70
years old)
52 participants
Questionnaire
Sep 2009 to
Feb 2010.
Interviews Apr
2008 to Feb
2009.
Yes
Feasibility Study
22 participants
4 months
Diabetes
Randomised
Controlled Trial and
Qualitative
Evaluation
171 participants
(n = 98
intervention, n=
73 control)
3 to 6 months
Diabetes
Assessment of user
Data collected
N/A
22
6 months
6 months
Yes
Yes
34
High
2014
35
High
2013
36
High
2013
37
High
1997
38
High
2014
among user
satisfaction, compliance, and
clinical outcomes of
telemedicine services for
glucose control.
Patient engagement
strategies used for
hypertension and their
influence on selfmanagement attributes.
Effects of tailored
telemonitoring on heart
failure patients'
knowledge, self-care, selfefficacy and adherence: a
randomized controlled trial.
Patient self-monitoring of
blood pressure and selftitration of medication in
primary care: the TASMINH2
trial qualitative study of
health professionals'
experiences.
Compliance with inhaled
medication and selftreatment guidelines
following a selfmanagement programme in
adult asthmatics
Smartphone-based home care
model improved use of
cardiac rehabilitation in
postmyocardial infarction
patients: results from a
randomised controlled trial
satisfaction
Home blood pressure
monitoring
Blood Pressure
Survey
Telemonitoring
device
Heart Failure
Randomised
Controlled Trial
Home blood pressure
monitoring
Blood Pressure
Randomised
Controlled Trial and
Qualitative Study
Asthma selfmanagement (peak
expiratory flow (PEF)
electronically
registered)
Asthma
Evaluation of Self
management
programme
Home monitoring
through smart phone
use
Heart Failure
Randomised
Controlled Trial
23
from 81
patients who
used
telemedicine
services
215 surveys
returned (twothirds of
participants
aged over 65
years old)
382 (aged 71 +/SD 11.2 years)
Semi-structured
interviews with
13 GPs, 2
practice nurses
and 1
healthcare
assistant
24 participants
(age range 1865 years old)
120 participants
in traditional
centre-based
programme
(n=60) and care
assessment
N/A
12 months
Yes
Yes
N/A
6 weeks
Yes
6 week
cardiac
rehabilitation
and 6 month
selfmaintenance
Yes
Yes
39
High
2014
Design of a multi-site multistate clinical trial of home
monitoring of chronic disease
in the community in Australia
Telemedcare Clinical
Monitoring Unit
(CMU)
Chronic Disease
Intervention Control
Study
40
High
2009
Home spirometry
device
Lung Function
Retrospective, Cross
Sectional Study
41
Mod
2009
Mobile phone with
glucometer
Diabetes
Randomised
Controlled Trial
42
Mod
2012
Diabetes selfmanagement
Diabetes
Systematic Review
43
Mod
2009
Significance of patient
self‐monitoring for long‐term
outcomes after lung
transplantation
Mobile communication using
a mobile phone with a
glucometer for glucose
control in Type 2 patients
with diabetes: as effective as
an Internet-based glucose
monitoring system
Effects of type 2 diabetes
behavioural telehealth interve
ntions on glycaemic control
and adherence: a systematic
review
Effect of adherence to home
spirometry on bronchiolitis
obliterans and graft survival
after lung transplantation
Home spirometry
Lung
Transplantation
7-year Prospective
Cohort Study
44
Mod
2009
Telemonitoring
Heart Failure
Randomised
Controlled Trial
Adherence among
telemonitored patients with
heart failure to
pharmacological and
nonpharmacological
recommendations
24
platform cardiac
rehabilitation
(n=60)
25 test patients
each site
(n=125) and 50
case matched
control patients
(n=250)
298 participants
period
6-18 months
Yes
3 months
Yes
69 participants
3 months
Yes
49 articles
selected from
1027 results. 14
met criteria for
inclusion
226 participants
N/A
101 participants
Nonadherence
assessed
longitudinally
for 24 months
3 months
Yes
Yes
Yes
Yes
45
Mod
2001
46
Mod
2003
47
Mod
2007
48
Mod
2013
49
Mod
1996
50
Mod
1990
51
Mod
2013
52
Mod
2013
Compliance and effectiveness
of 1 year's home
telemonitoring. The report of
a pilot study of patients with
chronic heart failure
Self-reported compliance of
patients receiving
antihypertensive treatment:
use of a telemonitoring home
care system
Self-Measurement and SelfTitration in Hypertension* A
Pilot Telemedicine Study
Willingness of older adults to
share data and privacy
concerns after exposure to
unobtrusive in-home
monitoring
Monitoring progress after
lung transplantation from
home-patient adherence
A randomized trial to
improve selfmanagement practices of
adults with asthma
The effect of telemonitoring
at home on quality of life
and self-care behaviors of
patients with heart failure.
Introducing
the Adherence Strategy
Engineering Framework
(ASEF). Support for
developing technologybased self-care solutions.
Telemonitoring
Heart Failure
Pilot Study,
Randomised
Controlled Trial
20 participants
(10 controls, 10
intervention)
(mean age 75.2
years old)
50 participants
(mean age 52
years old)
12 months
Home-monitoring of
blood pressure
Blood Pressure
Evaluation
Home-monitoring of
blood pressure
Blood Pressure
Multicenter,
prospective, singlegroup, open-label
pilot study
Longitudinal Study
111 participants
8 weeks
Yes
Home-monitoring
and computer use
(in-home sensors)
Human Movement
119 participants
12 months
Yes
Electronic
spirometer/diary
instrument
Heart/lung
transplantation
Feasibility Study
41 participants
(24 female, 17
male)
12 months
80 participants
(40
intervention, 40
control)
7 case studies,
25 participants
90 days
12 months
Randomised
Controlled Trial
Home-monitoring of
blood pressure
Heart Failure
Randomised
Controlled Trial
(prospective design)
Home-monitoring of
blood pressure
Blood Pressure
Case Studies,
Feasibility Study,
Conceptual
Framework
25
53
Mod
2003
Effects of individual selfmanagement education on
clinical, biological,
and adherence outcomes in
asthma
M-health for long-term
management of COPD
54
Mod
2013
55
Mod
2011
56
Mod
2010
57
Mod
2014
58
Mod
2011
Uptake of a technologyassisted home-care cardiac
rehabilitation program
59
Low
2008
Use of a smartphone for
improved self-management of
pulmonary rehabilitation
Factors
affecting compliance of
diabetic patients toward
therapeutic management
Self-monitoring and other
non-pharmacological
interventions to improve the
management of hypertension
in primary care: a systematic
review
Heart failure patients'
perceptions and use of
technology to manage disease
symptoms.
Asthma selfmanagement
Asthma
Randomised
Controlled Trial
65 participants
(adults)
7 weeks
Self-management
application on a
tablet device
Therapeutic
management
COPD
Feasibility Study
23 participants
1189
monitoring
days
Diabetes
Descriptive
Correlational Design
80 participants
(23 males and
57 females)
Self-monitoring
interventions
Blood Pressure
Systematic Review
72 Randomised
Controlled Trials
met the
inclusion
criteria
Blood pressure
device or bathroom
scale
Heart Failure
Qualitative Analysis
15 participants
(mean age
64.43 years)
Mobile phone and
web based home
monitoring
Heart Failure
Randomised
Controlled Trial
Exercise programme
and selfmanagement at
home with smart
phone
COPD
Pilot Application
Traditional
cardiac rehab
(control group
n=80) vs Care
Assessment
Plan
(intervention
group n=80)
Full user
assessment and
clinical
evaluation
being planned
26
Yes
Yes
6 weeks
N/A
Yes
60
Low
2010
61
Low
2009
62
Low
2012
63
Low
2006
64
Low
2008
65
Low
2000
66
Low
1999
67
Low
2000
In situ monitoring of health in
older adults: technologies and
issues
Predicting need for
intervention in individuals
with congestive heart failure
using a home-based
telecare system
Telemedicine and telecare for
older patients—a systematic
review
Home monitoring
devices
Geriatric Care
Report
N/A
N/A
Telecare monitoring
system
Heart Failure
Feasibility Study
45 participants
(elderly)
18 months
Various Home
monitoring based
devices and systems
Chronic Disease
(generalised)
Systematic Review
68 papers
Diurnal and weekly rhythms
of health-related variables in
home recordings for two
months
Telehomecare for patients
with multiple chronic illnesses
Pilot study
Home monitoring
system
Physiological
measurements
(well-being)
Feasibility Study
14 participants
(all middle-aged
males)
Papers
published
between 2007
and Feb 2012
50 to 79 days
Home monitoring
system
Chronic Disease
(generalised)
Pilot Study (mixed
method)
9 to 339 days
Emergence of
Electronic Home
Monitoring in Chronic Heart
Failure: Rationale, Feasibility,
and Early Results With the
HomMed Sentry™‐Observer™
System
The effect of
physiologic home
monitoring and
telemanagement on chronic
heart failure outcomes
The effect of home
Home monitoring
system
Heart Failure
Multicenter Study
8 physicians and
5 nurses caring
for approx
10,000 patients
(sample of 22
from RCT on
240 patients)
53 participants
(78% male, 72%
Caucasian, age
range 17-79
years)
Home monitoring
system
Heart Failure
Feasibility Study
2 to 3 months
Yes
Home monitoring
Blood Pressure
Feasibility Study
60 participants
(61 +/- 13 years,
62% African
American, 67%
female)
33 participants
1 to 3 months
Yes
27
Statisti
cal
Measur
es
3 months
68
Low
2006
69
Low
2010
70
Low
2003
71
Low
2000
72
Low
2002
monitoring and
telemanagement on blood
pressure control among
African Americans
A systematic review of the
literature on home
monitoring for patients with
heart failure
Telemedicine for recently
discharged older patients
Current issues related
to home monitoring
Influence of peak expiratory
flow monitoring on an
asthma selfmanagement education
programme
The influence of
socioeconomic and
psychological factors on
patient adherence to selfmanagement strategies
system
(African
Americans, age
51.5 +/14.3,
70% female)
42 articles
included of 383
read
Home monitoring
systems
Heart Failure
Systematic Review
Home-based casemanaged
telemedicine
Home-monitoring
Chronic Diseases
Observational Study
851 patients
1951 to April
2004 (varies
depending on
database)
2 months
Chronic Diseases
Review Article
N/A
N/A
Home monitoring
Self-management
Asthma
Randomised
Controlled Trial
100 participants
(aged 17-65
years)
12 months
Self-management
strategies
Asthma
Review Article
N/A
N/A
28
Yes
Yes